Basic Information
| Provider Information | |||||||||
| NPI: | 1073919312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | DONGYOUN | ||||||||
| MiddleName: | DEBORAH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 CAPITAL WAY STE 220 | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093030747 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 CAPITAL WAY STE 220 | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093030747 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2014 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RX0202X | 25MA09947600 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3046303 | 05 | NJ | MEDICAID |